Provider Demographics
NPI:1871576694
Name:GOGARTY, WILLIAM SHAUN (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SHAUN
Last Name:GOGARTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SWIFT ARROW CT
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1800
Mailing Address - Country:US
Mailing Address - Phone:719-250-5326
Mailing Address - Fax:
Practice Address - Street 1:3225 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-9380
Practice Address - Country:US
Practice Address - Phone:719-275-2351
Practice Address - Fax:719-269-9386
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO34360207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01343607Medicaid
COCF9374Medicare UPIN
COF67217Medicare UPIN